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Wednesday, July 16, 2008

a fitting end

My last day of residency, I was taking home call for cardiothoracic anesthesia, and I have to admit, I was hoping for a softball. I figured I would get called in for something at the very least, but maybe something small, like a washout or a chest closure. The moving van was coming the next morning, and so I needed to request to be on call on Sunday so that I could have the next day off to, you know, be around as burly men carted off all my material possessions on dollies. I was hoping, perhaps naively, that I might actually get a chance to finish some packing. I would have been perfectly happy with an anticlimactic end to my residency. The universe apparently had other plans.

I already knew the night before that they had scheduled a BiVAD for the following morning to start at 8:00am--essentially, the placement of a mechanical ventricular assist device, often used in failing hearts as a bridge to transplant. So I knew already that I would be going in for that case, which would take a good couple of hours, at least until the afternoon, but I hoped...I mean, there was always the possibility...that the service would be quiet after that. There was nothing else looking ominous up in the CTICU. The OR desk had a blank slate otherwise, as far as they were concerned.

The BiVAD was going smoothly, patient doing well, when we got word that the thoracic team had just booked a lung transplant. Then, moments later, further word, that cardiac had booked a heart transplant. Same donor, two different patients. And that, as they say, was the ballgame.

Once my attending and I realized that the whole day was basically written off, I actually started to enjoy myself. "Going out with a bang!" I kept saying for the rest of the day. My attending was not quite so happy at how the cards had fallen (he's one of those brilliant sarcastic-types) but I think was pleased enough that it was my last day. "Why?" I joked, "Because I'm leaving, and you'll never have to put up with me again?"

"No," he answered, "because you're almost an attending, and I can basically leave you alone and let you manage things." He turned to the surgeons, the perfusionists, anyone that would listen. "Hey, in about eight hours, she's going to be an attending!" Everyone cheered, congratulations were lofted about. I thanked them, and nervously hoped that I was actually ready for all this.

There was a point, I believe, where we were running four cardiac surgery rooms at once. (There was one more case that got rushed in while I was still in with the BiVAD--a post-op bleeder.) It was insane. Thankfully, the general surgery add-on schedule was virtually empty, another unusual circumstance, but this at least allowed the general anesthesia call team to pitch in, the second year residents teeing up rooms to start and occasionally actually starting the cases. We even enlisted the help of two of our first year residents (first years for the next two days, anyway) to help finish a case as the surgeons were closing, transfusing blood products and running blood gases as I ran next door to start one of the transplants. Neither of them had done their cardiac rotations yet, and as I signed out to them and explained the monitoring and told them what to watch out for before sprinting to the OR next door, I saw their hubcap-sized eyes floating over their masks and gave them this empty comfort: "Don't worry, you guys are going to be fine." I remember how many times I've been told that during my training, when I've been put in situations that I felt were completely beyond me, and how meaningless that seemed--"What do you mean I'm going to be fine? How about the fact that I don't know what I'm doing? What's going to happen to the patient?"--and yet, it was. Fine, that is. The attending popped in and out, the second year residents helped out, and the patient made it up to the ICU a few hours later, humming VADs in tow.

How fitting, really, to do a heart transplant as one’s last case of residency. Much like the process of medical training, an organ transplant takes the ordinary and transposes it into extraordinary circumstances—in this case, taking the heart of a freshly deceased patient and having it work in the body of a patient who still might be saved. The recipient that day was a 57 year-old man with dilated cardiomyopathy—with a sick and dying heart that did not beat so much as feebly tremble, barely moving enough blood through his body to keep his organs alive. The sight was quite impressive really, once the patient was anesthetized and the sternum was sawed open to reveal the chest cavity underneath. The patient's old heart was huge, congested, an angry and mottled looking purplish mass looking more like a dead thing in a butcher’s window than anything else. We worked together to get the patient onto cardiopulmonary bypass, the surgeons snipped the old heart out, and suddenly the chest cavity was huge, empty, a yawning expanse waiting to be filled.

For surgery scheduling, there is usually what we call a "send time" and a "cut time," the send time being the time that the patient should be physically wheeled into the OR, and the cut time being after induction of anesthesia and placement of all the necessary monitoring and lines, that the surgeons will be making initial incision. In organ transplants, this is all rigorously timed to coincide with the trajectory of the harvested organ--when the clamp the old heart from the donor, how long it will take them to drive (or in this case, fly) back from the harvest site, when they think the organ will be physically arriving into the hospital. All this is designed to minimize the ischemic time of the new organ, the amount of time that the organ needs to be on ice; basically, the shorter the ischemic time, the better the organ will perform.

However, as with anything in the hospital, the timing was not as precise as planned, and so after we went on bypass, after the old heart was out, there was some stalling. During the wait, which seemed interminable after all the rush, we exchanged stories of transplants past, one in particular where one member of the harvest team grabbed the Playmate cooler with the organ, jumped out of the ambulance, and simply ran across the George Washington Bridge as fast as he could to the hospital, rather than wait for the upper deck to clear. We laugh at this image for a little while, all the while noting how fucking cool it would be to be able to tell the family offhand afterwards that yes, that was me, I didn't want to keep you all waiting, so I ran your heart across the bridge.

Finally, with some fanfare, the new heart for our patient arrived, about 25 minutes later than predicted. The harvest team, we gathered, had been stuck in some traffic. The heart was double-bagged and floating in a slurry of ice, looking small and cold and waxy. The surgeons peered at it intently, turning it over in their hands, occasionally trimming small pieces away in preparation for the anastamosis.

As new connections were made, the patient, who had been cooled down for his run on bypass, was gradually allowed to warm up, and with him warmed his new heart. It twitched irregularly at first, then started to beat. Its waxy, clay-like appearance melted away as the heart filled with the patients blood, and it flushed pink, then bright red. It needed to be shocked once, twice, with internal defibrillation paddles, and the anastamoses were tested, checking for leaks, but by the time the surgeons started to close the sternum, the heart was beating vigorously, snappily, fairly jumping out of the chest like healthy hearts do. The heart looked like it knew what it was doing. As though it had known what it was supposed to do all along.